NEW DELHI: Across India, there have been some instances of hospitals having closed down as when health care workers (HCW) working there turned out to be positive for COVID -19. Also, some non-COVID health facilities have reported confirmation of COVID-19, in patients admitted for unrelated/nonrespiratory illness, causing undue apprehension among healthcare workers, sometimes leading to impaired functioning of such hospitals.
Although the Ministry of Health & Family Welfare has issued comprehensive guidance to prevent the occurrence of Hospital Acquired Infection (HAI) in health facilities, the practice of universal precautions might still be lacking in many of India’s hospitals. A COVID-19 case with mild/asymptomatic/atypical presentation may go undetected and inadvertently transmit the infection to other patients and healthcare workers, putting these individuals at risk of contracting the disease and compromise the functionality of the healthcare facility.
The Health Ministry of the Government of India has announced the following guidelines to be followed on detection of suspect/confirmed COVID-19 case in a non-COVID Health Facility: (NOTE: The guidelines are relevant to both (i) COVID-19 healthcare facilities (public and private) which are already receiving or preparing to receive suspected or confirmed COVID-19 patients as well as (ii) Non-COVID healthcare facilities.)
The Hospital Infection Control Committee (HICC) has to have a well-defined composition, roles and responsibilities. This committee is responsible for establishing a mechanism for reporting of development of symptoms suggestive of COVID-19 in HCW.
These include surveillance for fever/cough/breathing difficulty through either self-reporting or active and passive screening at the beginning of their shift. The Committee will also monitor patients (who have been admitted for non-COVID illness) for development of unexplained fever/cough/breathing difficulty during their stay.
HICC will ensure that existing IPC guidelines against such high-risk situations must be audited, updated and reiterated to all HCW. Further, all IPC guidelines will be strictly adhered to and followed at all times. As a matter of abundant precautions for hospitals located in proximity/catering to COVID-19 containment zone/s it might be desirable to treat all patients as suspect COVID-19 case until proven otherwise and exercise standard care.
Whenever a non-COVID patient or any healthcare workers is suspected to have COVID like symptoms/tests positive for COVID-19, the HICC will come into action, investigate the matter and suggest further course of action as described below.
Action to be taken on detection of COVID -19 case in a non-COVID health facility When a positive COVID-19 patient is identified in a health care facility, not designated as COVID-19 isolation facility:
• Inform the local health authorities about the case
• Assess the clinical status of the patient prior to referral to a designated COVID facility
• The patient should be immediately isolated to another room (if currently being managed in a shared ward/room). If the clinical condition permits, such patients should be masked and only a dedicated healthcare worker should attend this case, following due precautions.
• If the clinical status of the case permits, transfer such case to a COVID-19 isolation facility (Dedicated COVID Health Centre or dedicated COVID Hospital), informing the facility beforehand about the transfer, as per his/her clinical status, test results (if available), with information to the local health authority. Complete case records of such patients must be made available to the receiving hospital.
• Follow appropriate standard precautions while transporting the patient
• This should be followed by disinfection procedures at the facility and the ambulance
• All contacts of this patient (other patients being managed in the same room or ward, healthcare workers who have attended to him/her, support staff who may have come in close contact, caretaker/visitors etc.) should be quarantined and followed up for 14 days. Their details must also be shared with the local health authorities.
• All close contacts (other HCWs and supportive staff) of the confirmed case should be put on Hydroxychloroquine chemoprophylaxis for a period of 7 weeks, keeping in mind the contraindications of HCQ.
• If a healthcare worker is suspected to have contacted the disease, the following additional action needs to be performed.
When a suspect/confirmed COVID-19 HCW is identified
• HCWs developing respiratory symptoms (e.g. fever, cough, shortness of breath) should be considered a suspected case of COVID-19.
• He/she should immediately put on a facemask, inform his supervisor and HICC. He/she should be isolated and arrangement must be made to immediately to refer such an HCW to COVID-19 designated hospital (if not already working in such a facility) for isolation and further management.
• He/she should be immediately taken off the roster
• Rapidly risk stratify other HCWs and other patients that might have been exposed to the suspect HCW and put them under quarantine and follow up for 14 days (or earlier if the test result of a suspect case turns out negative). Their details must also be shared with the local health authorities.
• All close contacts (other HCW and supportive staff) of the confirmed case should be put on Hydroxychloroquine chemoprophylaxis for a period of 7 weeks, keeping in mind the contraindications of HCQ.
• All health facilities (HCF) must have a staffing plan in place including a contingency plan for such an event to maintain continuity of operations. E.g. staff in HCF can be divided into groups to work on a rotation basis every 14 days and a group of back-up staff which is pooled in case some high-risk exposure/HCW with suspected COVID-19 infection is detected.
• Ensure that the disinfection procedures are strictly followed.
Once a suspect/confirmed case is detected in a healthcare facility, the standard procedure of rapid isolation, contact listing and tracking disinfection will follow with no need to shut down the whole facility.
The decision on further /continued use of non-COVID facilities where a single/multiple COVID-19 case has been reported:
The likely scenarios could be:
– Socio-demographic reasons:
a) Hospital’s catchment area is a large cluster of COVID-19.
b) The catchment area is having a population which has a large number of vulnerable individuals having multiple co-morbid conditions, poor nutritional status and/or having individuals not able to practice social distancing e.g. slum clusters.
– Internal Administrative Reasons:
a) The health facility is not up to the mark in IPC practices.
b) Non-fulfilment of guidelines regarding the triaging of patients in the outpatient department and emergency.
Based on the scope of the cluster and degree to which the hospital has been affected (HCW patients, and HCW contacts), degree of the risk to the patients visiting the hospital such as those with chronic diseases etc. the decision can be made based on a risk assessment to:
• If the hospital authorities are reasonably satisfied that the source case/s have been identified and isolated, all contacts have been traced and quarantined and adequate disinfection has been achieved, the hospital will continue to function.
• In addition to steps taken above, if the health facility still continues to report new hospital-acquired COVID-19 cases in the following days, it would be advisable to temporarily close the defined section of the health facility where the maximum number of HAI is being reported. After thorough cleaning and disinfection, it can be put to use again.
• Despite taking the above measures, if the primary source of infection could not be established and/or the hospital is still reporting a large number of cases among patients and HCWs a decision needs to be taken to convert the non-COVID health facility into a COVID health facility under intimation to the local health department. In such a scenario, the entire healthcare workers of the facility should be oriented in Infection Prevention and Control practices and other protocols for which guidance is available at www.mohfw.gov.in.
Follow up actions
When a non-COVID health facility reports a COVID-19 case, the HICC will ensure the following in order to minimize the possibility of an undetected contact/case amongst other patients/HCWs:
• Ensure that active screening of all staff at the hospitals is done daily (by means of thermal screening especially at the start of shift)
• All healthcare and supportive staff is encouraged to monitor their own health at all the time for the appearance of COVID-19 symptoms and report them at the earliest.
• Be on the lookout for atypical presentation (or clinical course) of admitted patients
• Standard precautions to be followed diligently by all
• Follow all guidelines regarding the triaging of patients in hospital emergency and outpatient departments.